Updated Guidelines for Severe TBI Still Have Holes

Lack of evidence in many areas precludes recommendations on care

Action Points

New guidelines for managing severe traumatic brain injury (TBI) are an update of all available evidence and recommendations since the guidelines published in 2007, including 189 publications with evidence supporting 28 recommendations on 18 topics.

Be aware that the guidelines include 14 new or changed recommendations and 14 unchanged recommendations, while evidence to support seven previous recommendations did not meet current standards.

New guidelines for the management of severe traumatic brain injury (TBI) provide an update of all available evidence and recommendations since the third edition of the guidelines was published in 2007, researchers reported -- but, sadly, it lacks answers to many key clinical questions.

A total of 189 publications provided evidence to support 28 recommendations on 18 topics in Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition, Nancy Carney, PhD, of Oregon Health and Science University in Portland, and colleagues reported online in Neurosurgery.

Endorsed by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons, the guidelines include 14 new or changed recommendations and 14 unchanged recommendations. Evidence to support seven previous recommendations did not meet current standards, experts said.

Despite major developments in the management of severe TBI, however, the guidelines do not include recommendations in many key areas because of a lack of evidence. As a result, the guidelines should not be considered a complete protocol for clinical use, the authors said.

"Protocols specific to individual clinical environments need to be developed to fill the gaps in evidence-based recommendations," Carney told MedPage Today. "Clinicians need to call upon their practical experience in the context of their particular environment to derive complete protocols."

There is insufficient evidence to support the use of hyperosmolar agents to improve outcomes, for example, and yet many clinicians have observed their value in daily practice, she explained: "Until there is evidence for or against this treatment approach, the neurosurgeon or critical care physician needs to make the call."

The CDC estimates that following the treatment recommendations in these guidelines could double the chances of survival for U.S. patients with severe TBI, increase the proportion of good outcomes for survivors from 35% to 66%, and decrease the proportion of poor outcomes from 34% to 19%, Carney noted.

"They estimated that with 80% adherence to these guidelines nationally, the annual total cost savings would net $4.08 billion," she said.

The guidelines specify the next steps in the research required to expand the evidence base, but studying individual topics isn't enough, Carney said. "The research needs to be conducted consistent with the highest standards in order for the results to be used as evidence."

Critical evidence gaps need to be identified, study designs improved, and state-of-the-art methods used for synthesizing and assessing evidence. In lieu of waiting for better clinical evidence to be produced, a formal consortium could focus on comparative effectiveness research that strictly adheres to evidence-based protocols rather than randomized controlled trials and observational studies, the authors proposed.

A fifth edition of the guidelines will not be forthcoming. Instead, "Living Guidelines" will use the latest technology to continuously monitor the literature. Evidence will be rapidly reviewed and recommendations revised as needed on an ongoing basis, the researchers said.

"A static document that is updated after several years no longer responds to the demands of the community we serve," they wrote.

In patients with severe TBI characterized by diffuse injury and elevated intracranial pressure (ICP) refractory to first-tier therapies, frontal decompressive craniotomy (DC) is not recommended to improve outcomes at 6 months post injury. This procedure has been shown to reduce ICP and to minimize time in the intensive care unit, however.

In patients with severe TBI, a large frontotemporoparietal DC (not less than 15 cm diameter) is recommended over a small frontotemporoparietal DC for reduced mortality and improved neurologic outcomes.

Maintaining systolic blood pressure at ≥100 mm Hg for patients 50 to 69 years old or at ≥110 mm Hg or above for patients 15 to 49 or older than 70 years may be considered to decrease mortality and improve outcomes.

The recommended target cerebral perfusion pressure (CPP) value for survival and favorable outcomes is between 60 and 70 mm Hg. It is unclear whether 60 or 70 mm Hg is the minimum optimal CPP threshold.

Financial support was provided by the US Army Contracting Command, Aberdeen Proving Ground, Natick Contracting Division, and the Brain Trauma Foundation. The guidelines authors disclosed no conflicts of interest.

Accessibility Statement

At MedPage Today, we are committed to ensuring that individuals with disabilities can access all of the content offered by MedPage Today through our website and other properties. If you are having trouble accessing www.medpagetoday.com, MedPageToday's mobile apps, please email legal@ziffdavis.com for assistance. Please put "ADA Inquiry" in the subject line of your email.